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I read with interest McSherry et al.'s (2004) spirituality-related study in a recent volume of Journal of Clinical Nursing (Vol. 13 pp. 934–941). It describes an attempt to conceptualize the term spirituality from a spectrum of health providers and users. This study adds to the extensive work already undertaken by McSherry et al. in this field. I was, however, somewhat disappointed by the fact that a very important facet of the spirituality dimension is virtually excluded – namely that of the existential domain. Reading the study further, I would argue that it was conducted in such a way that this was inevitable or, indeed, may have been deliberate.

I recently had an article published in the pages of Journal of Clinical Nursing which explored the affiliations and relationships between the metaphysical (very simply stated as religious orientated) and existential (similarly simply stated as non-religious orientated) dimensions of spirituality and their influences on the health status of clients (Whitehead 2003). My article presented a dilemma for me at the time of writing. It sought to delineate and separate the concept of an existential health state from that of a spirituality context. The main reason, at the time, for this was that existentialism is too rarely acknowledged in the nursing literature on spirituality (although this is changing of late) and, where it is, is mostly tagged onto or mentioned as a subclass of metaphysical spirituality. McSherry et al. (2004) believe that existentialism is a ‘subset’ of spirituality, but they do not apply a similar classification to metaphysical considerations. In effect, I have been championing existential health considerations against a rising tide of metaphysical dominance. Rightly or wrongly, my interpretations have been fashioned and shaped by those who seem determined to construct a spirituality-based context that heavily favours the metaphysical perspective. I do not believe that this is right or healthy and I believe that it is now prudent to draw a line in the sand. Existentialism should stand aside and equal to the metaphysical dimension of spirituality in nursing. As Cavendish et al. (2004) state, if we define spirituality purely within a religious (metaphysical) context then we omit care for those who have different ‘transcendent and relational needs’.

With a certain degree of unashamed ‘back-tracking’, on my part, McSherry et al.'s (2004) article has spurred me to write further on this matter. It is perhaps unfair to pick on this paper alone to vent my frustration with this situation, but some of McSherry's previous work also lends itself to this criticism. Whereas, previously I have sought to separate existential health states from a spirituality-based context, I now prefer to acknowledge their close relatedness. McSherry (2004) et al., however, do a number of things that, to me, suggest a heavy bias in exploring the metaphysical concepts of spirituality above other related contexts. Firstly, it draws its findings from a sample containing ‘people from the major world religions’ where material was distributed through ‘Trust's Chaplaincy teams’. Why purposively draw from such a sample group and distribute material in such a way – unless the intention was actively to seek a metaphysical perspective? The few participant responses in the article nearly all contain a direct mention of religion or religious-orientated activities. I wonder to what extent the study questions were framed purely within a metaphysical context? MacLaren (2004, p. 460) would presumably have issues if this were the case, as she argues that ‘…the narrowing of spiritual matters to religion is problematic because it ignores the spirituality that lies outside religion’.

Secondly, if I repeat the same stated literature review used in McSherry et al.'s 2004 study, using the same databases and keywords (a year range is not stated), I uncover a useful body of literature that clearly delineates the place of existential states in the nursing-related spirituality-based literature (i.e. Rustoen & Hanestad 1998, Smucker 1998, Strang et al. 2002, Whitehead 2003, Leeuwen & Cusveller 2004, McGrath 2004). Ironically, McSherry has recently stated that ‘it would appear that spirituality is concerned with existentialism…’ (Smith & McSherry 2004, p. 310). This being the case, where does it sit in this latest study and were there any attempts to unearth it within the review?

McSherry et al. (2004) clearly state that an overarching aim of their study was to gain a clearer understanding and conceptualization of what spirituality is for nursing – as does their ‘broad’ title. By omitting any consideration of the existential dimension, I argue that they do neither. They also state that, because such diversity exists, ‘a broad universal approach may be required, ensuring inclusion of all views’ McSherry et al., p. 939). They appear to have failed in this endeavour – otherwise where is the existential dimension? I would like to see a turning of the tide and therefore an acknowledgement that metaphysical dimensions of spirituality sit alongside existential dimensions of spirituality. In other words, a view that spirituality is a ‘combination of existential and religious’ dimensions (Laubmeier et al. 2004, McNulty et al. 2004). Future nursing spirituality-based studies, I argue, should take into account both dimensions and not steer their methods or intentions in favour of one over the other. It is too simplistic to suggest that religious-based studies explore the metaphysical dimension and that existential studies do not. Their relationship is not so easy to separate. I prefer Shealy and Myss’ (1993) suggestion that the only difference between the two positions is that metaphysical considerations emphasize an ‘external god’ reality whereas, for existential concerns, an ‘internal god’ reality prevails. I know that some readers might find that my arguments are merely semantic and only serve to confuse further the long-laboured efforts of those who wish for a defined consensus on what spirituality is and does. Efforts to acknowledge all dimensions of spirituality do not, in my mind however, serve to create an ‘all-inclusive’ or ‘catch-all’ context that makes it too difficult to ‘nail’ spirituality. It is instead essential that we travel this road. It is also essential that existential considerations are given serious consideration in future nursing-related spirituality-based research.

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